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We have read the interesting article from Hsu et al. [1], reporting the surgical outcomes for patients with corrected transposition of the great arteries (CTGA) who underwent physiological repair, anatomical repair and single ventricular palliation (SVP). With regard to lower mortality and morbidity after Fontan palliation in their cohort, the authors concluded that they prefer SVP in patients with complex anatomy. As Karl [2] from Brisbane listed in his review in 2011, potential advantages of Fontan palliation managing CTGA included technical simplicity, less arrhythmia, absence of a Rastelli conduit and less left ventricular outflow tract obstruction. More importantly, the left and right ventricle (RV) are both working as the systemic ventricle, theoretically eliminating the development of heart failure. In 2005, Hraska et al. [3] also proposed the role of Fontan palliation in complex CTGA. In the case with remote VSD, chordae straddling and anomalous pulmonary venous connection, this approach is fully justified with favourable shortto mid-term mortality and morbidity which was confirmed by the current study. However, there were some significant issues influencing the surgical outcomes. A potential confounding factor was that no patients who underwent SVP presented with preoperative tricuspid regurgitation which was the major manifestation of morphological RV dysfunction. As the authors in this study and Hörer et al. [4] in his previous study analysed, patients with significant tricuspid valve regurgitation showed the worse outcome after surgery, raising the question of whether the morphological RV function was a true risk factor rather than the surgical strategy? And why was there no tricuspid regurgitation in this group? Was tricuspid regurgitation a contraindication of SVP in the authors’ strategy? A study from Moscow [5] suggested that atrioventricular regurgitation increased the risk of poor outcome after SVP. Tricuspid insufficiency could limit Fontan function in the long term as it has in the physiological strategies as this valve is still subjected to systemic pressure. There is a lack of consensus when it comes to the timing of SVP. When was SVP or anatomical repair performed if a CTGA patient presented with no tricuspid regurgitation and no severe cyanosis? Moreover, clinicians are frequently impressed by the fact that patients with CTGA and pulmonary outflow obstruction fare better than those without. They can even survive decades with minimal or no symptoms and require no intervention. Interestingly, 78% (18/ 23) of patients in the SVP group had significant pulmonary obstruction. The pressure gradients and indication for SVP are required in detail to propose SVP as a preferred strategy. Of course, the authors should be congratulated for their excellent surgical outcomes and excellent analysis which transferred knowledge to us. As Karl [2] stated in his review, Fontan timing and technique might have a different influence on outcomes for CCTGA patients than for other true univentricular variants. Physicians may benefit from their detailed surgical strategy including the timing and indication for various approaches.

Tricuspid regurgitation in single ventricular palliation for corrected transposition